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VBCR - December 2016, Vol 5, No 6 - Best Practices
Alice Goodman

Washington, DC—Patients with inflammatory diseases are at increased risk for perioperative infection, which has been associated with significant morbidity and mortality. There is little guidance in the literature on how to manage antirheumatic medications in patients with rheumatoid arthritis and other inflammatory arthritic conditions who undergo joint replacement surgery, but that is about to change. Proposed guidelines on the perioperative management of antirheumatic medications in patients undergoing total hip and/or knee replacement were presented at the 2016 Annual Meeting of the American College of Rheumatology (ACR).

The guidelines represent a collaborative effort between the ACR and the American Association of Hip and Knee Surgeons, as well as input from a panel of 11 adult patients with rheumatoid arthritis or juvenile idiopathic arthritis who had undergone total hip and/or knee replacement surgery. The guidelines are currently under review, and publication is expected in early 2017.

“The majority of patients who come in for elective hip and knee replacement are taking some sort of potent antirheumatic therapy,” said Susan M. Goodman, MD, Associate Professor of Medicine, Weill Cornell Medical School, New York. Dr Goodman is a co-investigator for the new guidelines with Bryan D. Springer, MD, Fellowship Director, OrthoCarolina Hip & Knee Center, Charlotte, NC.

The draft recommendations are a work in progress. “All the recommendations the panel made are conditional. The benefits probably outweigh the harms, but not necessarily for all patients. Also, additional evidence could change them. They should be discussed with patients on an individual basis,” Dr Goodman told attendees.

“The members of the committee that drafted the recommendations felt that the burden of infection was greater than the burden of disease flare, and feared the potential for severe infection. We unanimously recommended that reducing the risk of infection was our overwhelming priority. The voting panel was 100% concordant that antirheumatic drugs should be timed to end at the end of a drug dosing cycle, and then surgery could take place,” she explained.

The first recommendation was to continue current dosing of methotrexate, leflunomide, sulfasalazine, and hydroxychloraquin in patients undergoing elective total hip or knee replacement.

“Despite a weak evidence base, the risk of infection is reduced when antirheumatic medications are continued,” Dr Goodman said.

Next, the panel recommended withholding all biologics before surgery for patients with inflammatory rheumatic diseases, and planning surgery at the end of a dosing cycle.

“Randomized controlled trials showed an increase in infection in the nonsurgical setting. We grouped biologics together because we didn’t have enough evidence on the drugs separately,” Dr Goodman explained.

The panel recommended that tofacitinib be withheld for at least 7 days before surgery for patients with rheumatoid arthritis, spondyloarthritis, or juvenile idiopathic arthritis.

“Tofacitinib carries the risk of serious infection. More research is needed,” she said.

For lupus, the proposed recommendation is to withhold rituximab and belimumab before surgery, plan surgery at the end of the dosing schedule, and restart rituximab at week 7 and belimumab at week 5 following surgery. For severe lupus, continue nonbiologics through surgery, based on indirect evidence, Dr Goodman continued. For patients with nonsevere lupus, withhold all medications for 7 days until 3 to 5 days after surgery.

Biologic therapy can be started in patients with inflammatory arthritis once the surgical wound shows evidence of healing (ie, approximately 14 days after surgery), sutures are taken out, and drainage has begun. Before restarting biologics, there should be no clinical evidence of postsurgical infection or nonsurgical infection.

The panel recommended continuing the daily dose of glucocorticoids for patients with inflammatory arthritis and scheduled elective surgery. This is preferred compared with supraphysiologic doses of glucocorticoid, she said.

Although more evidence from randomized trials is needed to support these recommendations, they were drafted using the best available evidence, bringing together the main stakeholders—rheumatologists, orthopedic surgeons, and patients.

“These are patient-centric and easy to apply. We hope they will be useful for busy doctors and help in clinical decision-making,” Dr Goodman stated.

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Last modified: February 1, 2017
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